| NPI | 1629398565 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110006005) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2010-06-02 |
| Last Update Date | 2024-08-08 |